12/10/2018

Building U.S. Capacity to Review and Prevent Maternal Deaths

Deborah Burch, Lead Nurse Abstractor, Consultant - CDC Foundation Nicole Davis, Senior Epidemiologist, CDC Division of Reproductive Health Julie Zaharatos, Partnerships and Outreach Manager, CDC Foundation

The Need

5

7

9

11

13

15

17

19

21

23

PRMR 1999–2013

MMR 1999–2014

13.2

17.3

9.8

21.5

Deaths per 100

,000

 births

1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014

PRMR: Pregnancy‐related mortality ratio MMR: Maternal mortality rate

http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html 2

1

http://www.cdc.gov/reproductivehealth/maternalinfanthealth/pmss.html

Deaths per 100

,000

 births

Deaths per 100

,000

 births

PRMR by State PMSS 2006-2013

35

30

25

20

15

10

5

0 States + DC

3

50 47.0

45

40 3.1 2.7 3.2 35 32.4

30 27.9

25

20

15 11.9 14.8

10 8.9

5

0 Lowest tertile states Middle tertile states Highest tertile states

NHB NHW

4

12/10/2018

2

12/10/2018

“So whose faces are behind the numbers? What were their stories? What were their dreams? They left behind children and families.  They also left behind clues as to why their lives ended early… It is the obligation of those who cared for and about these women to retrace their journeys through pregnancy in an effort to unravel the circumstances surrounding their deaths…” 

William Callaghan, CDC Maternal and Infant Health Team Branch Chief (Strategies to Reduce Pregnancy-Related Deaths, 2001)

5

Unique Role of MMRCs

CDC – National Center for Health CDC – Pregnancy Mortality Maternal Mortality Review Statistics (NCHS) Surveillance System (PMSS) Committees

Death certificates linked to fetal death Death certificates linked to fetal death and birth certificates, medical Data Source Death certificates and birth certificates records, social service records,

autopsy, informant interviews…

Time Frame During pregnancy – 42 days During pregnancy – 365 days During pregnancy – 365 days

Source of ICD-10 codes Medical epidemiologists (PMSS-MM) Multidisciplinary committees Classification

Pregnancy associated, Pregnancy associated, (Associated and) Pregnancy related, (Associated and) Pregnancy related, Terms Maternal death (Associated but) Not pregnancy (Associated but) Not pregnancy

related related

Pregnancy Related Mortality Ratio - # Pregnancy Related Mortality Ratio - # Maternal Mortality Rate - # of Maternal Measure of Pregnancy Related Deaths per of Pregnancy Related Deaths per Deaths per 100,000 live births 100,000 live births 100,000 live births

Understand medical and non-Analyze clinical factors associated Show national trends and provide a medical contributors to deaths, Purpose with deaths, publish information that basis for international comparison prioritize interventions that may lead to prevention strategies effectively reduce maternal deaths

Nicely reviewed in: • Callaghan, William M. 2012. Overview of maternal mortality in the United States. Seminars in perinatology. 36; 1: 2-6. • Berg C, et al. (Editors). Strategies to reduce pregnancy-related deaths: from identification and review to action. Atlanta: Centers for Disease Control and Prevention; 2001

6

3

12/10/2018

Power of MMRCs

Deaths

Near Misses

Severe Maternal Morbidity

Maternal Morbidity Requiring Hospitalization

Maternal Morbidity Resulting in Emergency Department Visit

Maternal Morbidity Resulting in Primary Care Visit

7

Power of MMRCs

Eliminate Deaths preventable 

maternal deaths

Near Misses Reduce maternal morbidity

Severe Maternal Morbidity

Maternal Morbidity Requiring Hospitalization Improve 

population Maternal Morbidity Resulting in health of 

women Emergency Department Visit

Maternal Morbidity Resulting in Primary Care Visit

8

4

12/10/2018

Opportunity

promotesthe maternal mortality review process as the best way to understand why maternal mortality in the United States is increasing, and identify interventions to prevent maternal deaths. The initiative

. It is the result of a collaboration between the CDC Foundation, the Centers for Disease Control and Prevention (CDC), and the Association of Maternal and Child Health Programs (AMCHP). Funding for the collaboration was provided through an award agreement with Merck on behalf of its program.

Strategies

• Systematic data collection and use Maternal Mortality Review Information Application (MMRIA)

• Technical assistance and training In-person and distance-based, conferences

• Innovate Socio-spatial dashboard, Informant Interview

9

General Health Services

Reproductive Health Services

Behavioral Health Transportation

Social and Economic

Primary care provider availability

Obstetrician availability

Mental health provider availability

Rural/Urban composition

Persistent poverty

Medicaid eligible

Certified Nurse Midwife 

Frequent mental distress

Car ownership Violent crime

availability

Uninsured Family planning 

Unmet substance use 

needs Public transit availability

Income inequality

10

5

12/10/2018

Resources

- Authorities and Protections - Mission and Vision - Policies and Procedures - Multidisciplinary Membership - Identify Cases for Review - Time and Cost Estimator for

Staff and Committee Meetings

- Data Strategy - Logic Model

11

Resources

Resources MMRC Abstractor Manual • Comprehensive and efficient gathering of information

• Modules by common causes of pregnancy-associated/-related deaths

MMRC Abstractor Workbook 4 fictitious cases, incl. medical records, social and environmental profile, case narrative and committee decisions • Cardiomyopathy • Hemorrhage • Overdose • Preeclampsia

12

6

12/10/2018

Resources

• Addresses barrier identified by MMRCs (2012)

• Built with expert input

• Lessons learned from precursor (2014-2016)

• One stop shop

• Comprehensive, but standardized http://mmria.org/

• Common language for reviews to work together

• 26 jurisdictions using MMRIA, 7 preparing to use

13

Resources

• Multi-user data entry • Unique user roles

• Abstractor • Administrator • Committee member

• Printable case narrative and case details • Standard reports • Training available for

• Abstractors • Data analysts

14

7

http://mmria.org

12/10/2018

Resources

• Ad hoc analysis • Data export to .csv, .xls, SAS, etc. • Compatible with multiple operating systems • Geocoding of all locations captured:

• Residence • Facility • Allows place-based information to be brought

into committee discussions and analysis(without identifiers)

15

Resources

• Process flow maps • Motion graphic videos • And more! Visit

reviewtoaction.org

16

8

https://reviewtoaction.org

12/10/2018

MMRCs: Where we are today

ME

WA VT

NH MAMT ND

MN NYOR RIID WI

SD MI CT WY PA New York City MD NJ

DEIA OH Philadelphia

NE IL IN

NV WV VA Washington D.C.

UTCA CO KY

KS MO NC

TN SC

OK AR AZ NM

GA AL

MS

AK TX LA FL

PR Existing Review

HI Planning a review 17 Unknown / No review

Data Action

18

9

12/10/2018

Data Action

MMR Data-Driven Campaign to Prevent Deaths from

Pregnancy-related Depression and AnxietyPostpartum.net/Colorado

Get the  Know the  Find the Facts Symptoms Right Help

19

Data Action

Emergency Obstetric Simulation Drills

20

10

https://Postpartum.net/Colorado

12/10/2018

Report from Nine Maternal Mortality Review Committees

The Data • 9 Committees

• 855 potentially pregnancy-related deaths

• 680 valid pregnancy-associated deaths for which

pregnancy-relatedness could be determined

• 237 pregnancy-related deaths

22

11

12/10/2018

The Data • Two questions overlap with PMSS

• Four questions unique to committee

data

23

Was the Death Pregnancy-Related?

12

12/10/2018

25

Distribution of Pregnancy‐Related Deaths by Timing of Death in Relation to Pregnancy

What was the Cause of Death?

13

12/10/2018

27

Leading Underlying Causes of Pregnancy‐Related Deaths

Was the Death Preventable?

14

12/10/2018

Preventable there was at least some chance of the death being averted by one or more reasonable changes to patient, family, provider, facility, system, and/or community factors.

29

Preventable there was at least some chance of the death being averted by one or more reasonable changes to patient, family, provider, facility, system, and/or community factors.

30

15

12/10/2018

Distribution of Preventability Among Pregnancy‐Related Deaths

31

Distribution of Preventability Among Pregnancy‐Related Deaths, by Cause of Death

32

16

 

34

12/10/2018

What were the Factors that Contributed to this Death?

Distribution of Contributing Factors among Pregnancy‐Related Deaths

17

      

    

 

  

 

12/10/2018

Contributing factors by leading causes of pregnancy‐related death Hemorrhage

Factor Level (% of total factors)

Provider (31.0%)

Most Common Factor Class(es) (% of level‐specific classes)

Assessment (33.3%)

Common Themes

Delayed or missed diagnosis or treatment Ineffective treatments

Knowledge (13.3%)

Failure to seek consultation

Systems of Care (36.0%)

Personnel (27.8%)

Inadequate training Inadequate or unavailable personnel

Policies/Procedures (19.4%)

Lack of applicable policies and procedures

Continuity of Care/Care Coordination (16.7%)

Lack of coordination and communication between providers that supports patient management

35

What are the recommendations and actions that address those

contributing factors?

18

12/10/2018

Recommendation themes: Improve training Enforce policies and procedures Adopt maternal levels of care/ensure appropriate level of care determination Improve access to care Improve patient/provider communication Improve patient management for mental health conditions Improve procedures related to communication and coordination between providers Improve standards regarding assessment, diagnosis and treatment decisions Improve policies related to patient management, communication and coordination between providers, and language translation Improve policies regarding prevention initiatives, including screening procedures and substance use prevention or treatment programs

37

Recommendation Themes for Action, with Select Examples Improve Training

Training on safe methods and medication during labor induction, including appropriate use of vacuum and forceps during delivery Provider education on how to perform cardiac exams

Training on caring for patients with drug addiction

Death certificate training for clinicians

Training for emergency room staff on the care of pregnant women

Training on how to administer mental health and suicide assessments and steps following positive results

Improve Procedures Related To Communication and Coordination Between Providers

Determine who will care for specific high‐risk obstetric patients and expertise required for procedures

Identify quality improvement procedures and implement periodic drills, including obstetric emergency drills for birthing hospitals Improve hand‐off communication

Improve communication with emergency  room staff 38

19

12/10/2018

What is the Anticipated Impact of Those Actions if Implemented?

40

Recommendation Themes for Action and Estimated Potential for Impact if Implemented, by Cause of Death

20

12/10/2018

What we are really excited about: • Significant progress towards providing comprehensive data

• Able to analyze all 6 key questions

• Recommendations for prevention

41

Stay tuned… • Manuscripts using data from 14 MMRCs • To be released over next year

42

21

12/10/2018

Discussion: Strategies for Large State Review

22